In many museum and academic collections around the world are examples of the earliest form of neurosurgery—skull trephination.1–4 A number of arguments and interpretations have been advanced by scholars as to the origin and surgical reasons for this early operation—to date no satisfactory answers have been found. Issues of religion, treatment of head injuries, release of demons, and treatment of headaches have all been offered. Unfortunately, no adequate archaeological materials have surfaced to provide us with an answer. In reviewing some of the early skulls the skills of these early surgeons were quite remarkable. Many of the trephined skulls show evidence of healing, proving that these early patients survived the surgery. Figure 1.1 shows examples of two early (Peru circa AD 800) skulls that have been trephined and show evidence of premorbid bone healing. In the Americas the tumi was the most common surgical instrument used to perform a trephination and some examples of these tumis are shown in Figure 1.1. In Figure 1.2 is a fine example of a well-healed gold inlay cranioplasty done by an early South American surgeon.

(From Breasted JH. The Edwin Smith Papyrus. Published in Facsimile and Hieroglyphic Transliteration with Translation and Commentary. Chicago: University of Chicago Press; 1930; from the author’s collection.)

A personality often overlooked in neurosurgical history was a prominent Persian/Islamic physician by the name of Haly Abbas (Abdul-Hasan Ali Ibn Abbas Al Majusi) (?AD 930-944). This writer from the Golden Age of Islamic medicine produced a work called The Perfect Book of the Art of Medicine,23 also known as the Royal Book (Fig. 1.10). Born and educated in Persia, a place he never left, it was here he produced his important writings on medicine. In his book he dedicated 110 chapters to surgical practice. A review of his work shows that his writings on spine injuries were essentially copied from the earlier Greek writers, in particular Paul of Aegina, and consisted mostly of external stabilization of spinal column injuries. Surgical intervention via a scalpel was rarely advocated. In his nineteenth discourse, Chapters 84 and 85 is clearly presented his management of depressed skull fractures. He also described the different types of fractures that can occur along with potential mechanisms of injury. He clearly appreciated that the dura should be left intact and not violated, the exception being those fractures where the skull bone had penetrated through the dural membrane, in which case these fragments needed to be removed. His technique of elevating a bone flap involved drilling a series of closely placed holes and then connecting them with a chisel. He showed some interesting consideration for the patient by advocating placing a ball of wool into the ears so as to block the sounds from the drilling. The head wound was then dressed with a wine-soaked dressing, the wine likely providing a form of antisepsis. In these chapters are also an interesting discussion about intraoperative brain swelling and edema, in which case the surgeon should look further for possible retained bone fragments and remove them. If later swelling occurred from too tight a head dressing, then it should be loosened. Unfortunately, Haly Abbas also advocated cephalic vein bleeding and inducing diarrhea for those who did not respond well; such primitive techniques were not to be abandoned until the mid-nineteenth century.

Constantinus Africanus (Constantine the African) (1020-1087) introduced Islamic medicine to the school of Salerno and thus to Europe (Fig. 1.13). Constantine had studied in Baghdad, where he came under the influence of the Islamic/Arabic scholars. Later, he retired to the monastery at Monte Cassino and there translated Arabic manuscripts into Latin, some scholars say rather inaccurately. Thus began a new wave of translation and transliteration of medical texts, this time from Arabic back into Latin.31 His work allows one to gauge how much medical and surgical knowledge was lost or distorted by multiple translations, particularly of anatomical works. It is also notable that Constantine reintroduced anatomical dissection with an annual dissection of a pig. Unfortunately the anatomical observations that did not match those recorded in the early classical writings were ignored! As had been the theme for the previous 400 years surgical education and practice continued to slumber.

Theodoric’s surgical work, written in 1267, provides a unique view of medieval surgery.34 He argued for meticulous (almost Halstedian!) surgical techniques. The aspiring surgeon was to train under competent surgeons and be well read in the field of head injury. Interestingly, he argued that parts of the brain could be removed through a wound with little effect on the patient. He appreciated the importance of skull fractures, especially depressed ones, recognizing that they should be elevated. He believed that punctures or tears of the dura mater could lead to abscess formation and seizures. To provide comfort for the patient about to undergo surgery, he developed his own “soporific sponge,” which contained opium, mandragora, hemlock, and other ingredients. It was applied to the nostrils until the patient fell asleep. He describes results in improved comfort that were better for both patient and surgeon (Figs. 1.16, 1.17).

In 1518 a remarkable book by Giacomo Berengario da Carpi (1460-1530) appeared.47 This book came about because of Berengario’s success in treating Lorenzo de’ Medici, Duke of Urbino, who had received a serious cranial injury and survived. In a dream that occurred shortly after this episode Berengario was visited by the god Hermes Trismegistus (Thrice-Great Mercury), who encouraged him to a write a treatise on head injuries. As a result of this dream Berengario’s Tractatus appeared and was the first printed work devoted solely to treating injuries of the head. Not only are original surgical techniques discussed but also illustrations of the cranial instruments for dealing with skull fractures are provided (Fig. 1.20